regard to the length of our hearings, but at this point we can certainly sacrifice a few hours. You may proceed. Secretary RICHARDSON. Mr. Chairman and members of the committee, the 1972 budget for the Department of Health, Education. and Welfare is a budget of change. It would move many of our most important programs in new and exciting directions. Where inequities exist (and the current welfare system is one huge inequity), it seeks to restore a just balance. Where programs have become outmoded and irrelevant (such as impacted area aid and equipment and minor remodeling) it seeks to reorient them toward contemporary priorities or to eliminate them altogether. Where new opportunities exist to make significant advances toward the solution of important social problems (such as in cancer research and the health manpower shortage), it seeks to exploit them by mounting special Federal initiatives. Where programs have multiplied to an alarming degree and program control has slipped away from the people whose lives are most profoundly affected by them (such as in the proliferation of elementary and secondary education programs), we seek to simplify them and give States and localities greater authority for allocating money and making program decisions. In short, the 1972 budget for HEW is directed toward the great goals which the President set for us in the State of the Union message. Because this is a budget which seeks new directions, much of it is dependent upon the enactment of new legislation. I shall accordingly be discussing our legislative proposals to a greater extent than is normal at an appropriation hearing. I think this is necessary, so that you can relate the many parts of our budget to our overall strategy of reform. HEALTH PROGRAMS The President's special message on health will present a new strategy for attacking the Nation's health problems. I would like to highlight those programs in our budget which will play an important role in carrying out this strategy. CANCER RESEARCH INITIATIVE As the President announced in his State of the Union message, the 1972 budget includes $100 million to mount a full-scale attack on cancer. This $100 million is over and above the $232 million regular budget request for the National Cancer Institute. There is widespread agreement in the scientific community that our scientific and technical resources are sufficient to make a concerted effort to conquer cancer. The new initiative will build on the very substantial recent progress in molecular biology and virology, and focus on both the prevention and treatment of this disease. An important dimension of the cancer initiative will be to lay the groundwork for expanded research effort. This will include the development of an overall plan of attack, recruitment and training of specialized staff, purchase of equipment, and it may, to a limited extent, require the construction and renovation of special facilities. We are working hard on this plan of attack and hope to have it ready for your review in the very near future. HEART DISEASE Arteriosclerosis is the major cause of heart attacks, causing 800,000 deaths per year. In 1972, the National Heart and Lung Institute will program $61 million to continue a major effort to prevent and control arteriosclerosis. Between 25 and 30 special research centers are now being established throughout the country to focus research efforts on effective ways to prevent heart attacks. In addition, a number of lipid research clinics will be set up to develop new ways to detect and cure circulatory disorders which indicate that a heart attack may occur. Mr. FLOOD. Lipids? Secretary RICHARDSON. This has to do with fat in the blood. Lipid is a fat and is associated with the obstruction of circulation. SICKLE CELL ANEMIA The Heart Institute budget also includes $5 million to expand research on sickle cell anemia. This is an hereditary blood disease which afflicts the black population and results in the unnecessary death of many young adults. The increase will be directed toward developing better methods to treat and prevent it. Mr. FLOOD. Are you suggesting this is restricted entirely to the black population? Secretary RICHARDSON. No, it isn't entirely so restricted, but it is primarily so. In the United States the incidence of the disease is significantly higher-I don't have a figure showing the percentage. Mr. FLOOD. You might at this point in the record insert those figures. Secretary RICHARDSON. I will be glad to do that, Mr. Chairman. (The information follows:) FREQUENCY OF SICKLE CELL ANEMIA DISEASE Although the incidence of sickle cell anemia is virtually unknown in the caucasian race, the frequency with which gene containing sickle cell trait occurs in the American black population is estimated at between 7 to 10 percent. Since the gene must be inherited from both parents for the disease to be manifest in an individual, approximately one in 500 black children in America is apt to be afflicted. However, since the life expectancy of affected persons is markedly shortened, the prevalence of the disease at any one time among the black population would be closer to one in a thousand. Thus, we can assume that there are presently about 30,000 individuals in our population afflicted with the disease, and that 2 million to 3 million parents are acting as carriers of the sickle cell trait. HEALTH MANPOWER The Nation's health manpower problems have four principal causes: 1. There is a shortage of almost every type of health professional and subprofessional. 2. The health manpower we do have is not equitably distributed. 3. Adequate use is not being made of allied health personnel. 4. It is difficult for the medical practitioner to keep current with the latest advances in medical science. The legislation authorizing the Federal health manpower programs expires at the end of fiscal year 1971. This gives us the opportunity to reorient the manpower programs to make them more responsive to the Nation's health problems. The current legislation provides a capitation payment to medical, dental, and related schools based on the number of students enrolled. We are proposing to switch to a capitation payment based on the number of expected graduates. The Federal subsidy would be strictly related to the output of the health professions schools rather than the number of students which go into them. We feel that this will encourage schools to make special efforts to keep medical students in school until they graduate, thereby increasing the supply of health manpower more than would be the case if the capitation payment were tied simply to enrollment. Most medical and dental schools now require a 4-year course of instruction. We believe there is enough evidence to show that a carefully reorganized curriculum can impart the same quantity and quality of education in a 3-year period. The proposed capitation payment would be an incentive for medical schools to shorten their curriculum. Since the capitation payment will be the same for each graduate, the school that switches to a 3-year program would receive a greater Federal subsidy per student-year than a 4-year school. Mr. FLOOD. Years ago we had the so-called combination courses where you could take the A.B. degree and in the last year start your graduate work. Secretary RICHARDSON. It is possible but it is not necessarily associated with this. Mr. FLOOD. You recall what I refer to? Secretary RICHARDSON. Yes. You go through a combination of college and medical school in 4 years with some overlap. Mr. FLOOD. Yes. Secretary RICHARDSON. The primary interest is on shortening of the medical school education itself, although a way of doing that is what you suggest. Mr. SMITH. Is a school that only offers 2 years toward a degree eligible for support? Secretary RICHARDSON. It would get a proportional payment based on half of the total available to the 4-year schools, since, from its point of view, the man who finishes 2 years is a graduate. Mr. FLOOD. You are speaking of what we call the old premed course. Mr. SMITH. Some people think this is the best way to expand the number of the graduates. Some of these schools could provide students 2 years and then they would go to other schools. Secretary RICHARDSON. I think it is a good way to expand education. It can grow on the basic science resources which are part of the university without necessarily having also to provide the clinical re sources. AREA HEALTH EDUCATION CENTERS Another provision of the proposed extension legislation would encourage the establishment of area health education centers, which would be associated with medical school science complexes and with other health education institutions such as community colleages. The centers are intended to fulfill a twofold role. Mr. FLOOD. When you say community colleges, you wouldn't exclude the extension schools of established universities? For instance, Penn State has a number of allied schools separate and distinct from the community colleges. You don't preclude them, I hope. Secretary RICHARDSON. No. What is involved here basically is the creation of a center for continuing education and for the postgraduate training of doctors in areas that are too sparsely populated to support a medical school as such. The centers are intended to fulfill a twofold role. They would be the primary vehicle for the continuing education of practitioners in the field. In addition, because they would function as extensions of the university medical science centers to places which do not now have access to these resources, they would attract medical personnel to practice in more remote areas. The medical practitioner would no longer have to be divorced from the university science center in order to work in a rural area, a small town, or a big city ghetto. The area health education center would, therefore, be an important factor in improving the distribution of our health manpower resources. I might add, Mr. Chairman and gentlemen, the concept is one which we initially encountered and adanted from the recommendations of the Carnegie Commission on Higher Education which wrote, we think, a very valuable report on medical education. Mr. FLOOD. I have the impression that your administration is stressing distribution, aren't you? Secretary RICHARDSON. Yes. I believe we seek to identify deficiencies and disparities in the existing health care system and then will propose specific remedies for those problems. Certainly the distribution of health manpower is one of the most glaring of these problems. The 1972 budget shows a $124 million increase in institutional support for medical, dental and related schools. This will provide funds to establish 20 to 30 area health education centers, expand capitation payments and assist medical schools in financial distress. AUXILIARY HEALTH MANPOWER The 1972 budget continues programs started last year to expand the use of physicians' assistants. Operation MEDIHC, which stands for Military Experience Directed Into Health Careers, is now operational in 47 States, Puerto Rico, the Virgin Islands, and the District of Columbia. This is a referral program which attempts to encourage a greater proportion of the 30,000 medical corpsmen discharged from military service every year to enter a civilian health occupation. Past experience showed that about 60 percent of these did not go into health careers. The successful operation of MEDIHC suggests to us that this loss can be reduced to about 30 percent. Mr. FLOOD. Do you have age limits? Secretary RICHARDSON. I don't think so. I think it is a matter of picking men up at the point of discharge from military service. In the case of a career man who has been in 20 years or so, he could still be young enough for an adequate period of service. HEALTH MAINTENANCE ORGANIZATIONS I might just add here for the interest of the committee that one of the proposals that will be contained in the President's Message on Health that bears most directly on the utilization of allied health personnel, particularly physicians' assistants, is the proposal whereby we could enter into a contract with a group practice prepayment plan, what we call a health maintenance organization. Pursuant to the terms of that contract, we would invoke the clause of the Constitution to displace State law restrictions against the delegation of responsibilities by a physician to a physician's assistant. LIMITATIONS ON USE OF ALLIED HEALTH PERSONNEL Mr. SMITH. I think a lot more of these boys would enroll in such courses but for the fact that after they are qualified they really can't fully use their skill and nurses are not permitted to do all they should do. Both are limited due to restrictions in State laws and medical practice on delegation of responsibilities. Secretary RICHARDSON. The limitations of State laws and the fear of malpractice suits are both significant factors here. Under limitations of State law, we would be able to, assuming our proposal is enacted, deal with the problem of malpractice as it affects this particular situation. Also malpractice will be subject to intensive study by a commission which the President will ask me to get together as soon as we can do it. We have given quite a lot of thought to the problem and felt it was so complicated and controversial we couldn't propose legislation without having quite a broad based representative group to take a look at it. Mr. SMITH. I wrote a letter to the President on this. I think the President could call these people in from the allied professions, paramedical groups consumer groups, and health-care institutions and get them in a room like when you mediate a national labor dispute and say, "Look, we have to come up with a program to meet the needs of the American people." I believe that if this were done at the President's level, we could come up with some kind of a practical action program. These States and the various medical associations have changed their attitudes. We should have national leadership on it right at this point. Secretary RICHARDSON. I agree there has been a considerable change of attitude. It is an interesting idea, getting people together. Mr. SMITH. Go into these licensing and certification problems. I think if interested parties were all in one room, under pressure from the President, he can get a program going. Secretary RICHARDSON. That is certainly an idea worth considering. MEDEX Another auxiliary manpower project, called MEDEX, is an effort to get medical corpsmen to work in rural areas under the supervision of a physician. It is more than a referral program. It includes shortterm training and follow-up once the corpsman is on the job. We are supporting five projects and they have all shown that well-trained physician assistants can materially improve the efficiency of a physi |